MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
930 Wildwood Drive
BUREAU OF IMMUNIZATION ASSESSMENT AND ASSURANCE
Jefferson City, MO65109
REQUEST FOR OFFICIAL STATE OF MISSOURI IMMUNIZATION RECORDS
573.751.6124
FAX: 573.526.0238
Please complete this form by typing or printing all required fields indicated by an asterisk (*).
Fax this request to 573.526.0238 Please call 573.751.6124 for assistance.
PATIENT INFORMATION
*FIRST NAME *LAST NAME MIDDLE NAME MAIDEN NAME (IF APPLICABLE)
*DATE OF BIRTH (MONTH/DAY/YEAR) GENDER DEPARTMENT CLIENT NO. (DCN) OR MEDICAID NO.
MALE FEMALE
*LAST FOUR DIGITS OF SSN *CURRENT ADDRESS AND TELEPHONE *PREVIOUS ADDRESS AND TELEPHONE
OR AND
*REQUESTOR RELATIONSHIP TO CLIENT
HEALTHCARE PROFESSIONAL SCHOOL CHILDCARE PARENT/GUARDIAN/CUSTODIAN SELF
OTHER (PLEASE SPECIFY)
REQUESTOR INFORMATION
*FIRST NAME *LAST NAME
*ORGANIZATION TITLE
EMAIL ADDRESS *TELEPHONE NUMBER FAX NUMBER
ADDRESS CITY STATE ZIP CODE
*INDICATE HOW IMMUNIZATION RECORD SHOULD BE SENT TO REQUESTOR
FAX EMAIL (ENCRYPTED FOR CONFIDENTIALITY) US MAIL
SIGNATURE
REQUESTOR SIGNATURE
FOR BIAA STAFF USE ONLY (CHECK, DATE AND INITIAL ONCE COMPLETE)
INITIALS/DATE
SENT DENIED
MO 580-3076 (7-14)
